TRADE Application # /D TIL tO
Harnett County Central Permitting #V87a
PO Box 65 Lillington, NC 27546
910 - 893 -7525 Fax 910 - 893 -2793
www.harnettorg/permits
Certification of Work Performed By Owner /Contractor
(Individual Trade Application) �p
Owner (s) of Structure: f / it I �._. S _ l '3 % 1 i Phone: �- p
-- 6 3e&
AO Owner (s) Mailing Address: I • 1 2 " R Fns PO 74
Nt..th — ik, .r... . /1.1 C- 2752e
Land Owner Name (s): Q l,/ I� Phone:
Construction or Site Address: 10 '70 T eFp
PIN or Parcel # from GIS: I
Job Cost: Description of Work to be done
Mechanical: New Unit With Ductwork _ New Unit Without Ductwork _ Gas Piping
Electrical *: 200 Amp _ <200 Amp _ Service Change V Service Reconnect _ Other
For Progress Energy customers we need the premise number
Plumbing: Water /Sewer Tap Number of Baths Water Heater ,
Specific Directions to Job from Lillin. on: /
rfp /ry ,rp C ' P / i 4 c A e/7 1 5 -tieiN GPI
�- Pon /- hv/e,S,,t4
Subdivision: Lot #:
I� 1
I s *Lore/ A. i4 / 2 will provi the ��C'G/ / Cf L- labor on this structure.
(Contractors Name) (Trade)
I am the building owner or my NC state license number is 5s 7 5 -T , which entitles me to
perform such work on the above structure legally. All work shall comply with the State Building Code
and all other applicable State and local laws, ordinances and regulations.
Structure owner(s) signature: e � f�1 Date: 7 - 22
Company Name: S (i/1J 1 �
'`! Phon:/9. csav -
/
—' (
Address: o 2 '` e tj, _Col,' F 4r. his, 2....„ ounty:
1
Contractor's License #: S - / 1 5 mail Address: 7i 'a ,e'fSq /2.(//2.S/V i (40'7 •
Contractor's Signature: J11_ . /1 . ' /1 it 2 Date: 7-22 -,8
*Company name, address, & phone must match information on license.
Individual Trade Application 1 of 1 06/10
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